Keywords hospitals - language - Oncology - patient satisfaction - workload
Introduction
Human beings are vulnerable to numerous experiences that are pleasurable and sorrowful
in life. During hospitalization, patients' physical and psychological well-being can
be promoted by their individual experiences. Despite their physical ailment, some
people will find their hospital experience to be the best, most bearable, or worst
they have ever had. Good interpersonal relationships, ethical practice, and appropriate
behavior among the hospital staff will provide a better experience for a patient during
their hospital stay. Such experiences will result in better patient satisfaction in
the hospital. Professionalism at the highest level is expected of all professionals.
The way health professionals talk to the patient, how they are being treated, the
cleanliness of the hospital, dietary services, the cost of medical and hospital expenses,
and many other factors influence patient satisfaction.
The increasing competition in the healthcare industry promotes quality health services.
The prerequisite for improved healthcare service is available through advances in
healthcare technology, which change patients' expectations and opinions. Individual
involvement in the health sector is also increasing, resulting in increased costs
and high demand for better quality.[1 ] Being diagnosed with a life-threatening illness, such as cancer, is one of the most
traumatic experiences in a person's life.
During the initial phase of diagnosis and the treatment regimen, patients must receive
the highest priority of care from health professionals and family members. Nurses
working in oncology units should have additional training in oncology care, including
consideration of the patients' psychosocial, emotional, and spiritual well-being.
Nursing care quality can be measured based on patients' and family members' views.
Nursing care is an essential component of hospital service and is one of the most
important indicators of patient satisfaction. Nurses have to understand how patients
perceive things, which is a vital element for improving patient care.[2 ]
A hospital's reputation is determined solely by the ratings given by patients and
is based on nursing care. Quality nursing care entails meeting the needs and expectations
of patients by adhering to relevant standards/requirements and providing comprehensive
care throughout the nursing process. Primary care or acute care adult/ nurse practitioners
or nurse specialists are advanced-trained nurses who work in this field. However,
due to diverse challenges, most Indian hospitals cannot implement primary care. A
systematic review confirms that healthcare providers consider patient satisfaction
because of services provided differently to every patient. The contented patient may
be ready to advocate for and recommend the hospital to others.[3 ]
A study conducted at DEBRE Berhan Hospital in Ethiopia found that 49% of the patients
were satisfied with nursing care. The educational factors and previous admission were
the reasons for satisfaction.[4 ] Another systematic review using Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines to identify the factors that influence patient
satisfaction concluded that no universally accepted patient satisfaction measurement
system was available, and the elements of satisfaction varied globally.[5 ]
Presently, nurses perform various crucial roles, besides patient care. Patient safety
is the keystone of quality in a healthcare setting. The outcomes of poor-quality care
are mortality and morbidity. Nurses have a crucial position in monitoring and coordinating
care to reduce such adverse consequences. Nursing care quality is increased by appropriate
knowledge, empathetic care, adequate communication, a good organizational system,
and active contribution.
The quality of nursing care affects both the patient's prognosis and safety. Patient
satisfaction and patients' expectations of care are valid indicators of the quality
of nursing care. Communication with families may increase the satisfaction of their
hospitalized relatives. Nursing services are one of the essential components of hospital
services. Nurses must know which factors influence patient satisfaction so that they
can focus on those aspects of care. Hence, assessing satisfaction and identifying
barriers can help to enhance quality patient care. This study aims to find patient
satisfaction in oncology units and the barriers to nursing care quality.
Methods
A cross-sectional correlation design was used to assess patient satisfaction with
nursing care and barriers to quality nursing care in the oncology units of the selected
hospital in Mangalore. The independent variable was barriers to nursing care quality,
and patient satisfaction was the dependent variable. Permission was obtained from
the Institutional Ethics Committee (IEC/2019-2020 -1472 dated 10/04/2019) and the
hospital authorities. The research was carried out in a full-fledged, 1000-bed teaching
and super-specialty hospital with 12 broad specialties and 15 super-specialties located
around 16 km from the center of Mangalore city. Radiation oncology, medical oncology,
and surgical oncology are among the therapies accessible to cancer patients, as well
as a well-equipped daycare center that can accommodate both outpatients and inpatients
and staffed by experienced counselors. The daily bed occupancy of the unit varies
between 40 and 70. This facility employs approximately 25 registered nurses licensed
by a professional board to practice. There is no special training offered to nurses
to work in oncology units. The nurse-to-patient ratio is determined by the patients'
abilities. One nurse is responsible for 5 to 10 patients in general wards and one
to three patients in special areas. The calculated sample size included 100 patients
diagnosed with cancer and admitted to oncological units selected by convenience sampling
technique. Patients who had difficulties responding to questions were excluded from
the study.
The following tools were used to assess patient satisfaction and barriers to quality
nursing care. A proforma was used to collect demographic variables such as age, sex,
occupation, marital status, education, type of family, residential area, type of treatment,
number of caregivers, duration of admission, type, and stage of cancer. A Patient
Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ) was used to assess patient
satisfaction. PSNCQQ is a standardized scale developed by Laschinger et al,6 to measure patient satisfaction with nursing care quality. It is a Likert scale that
ranges from one to five, on which one is poor, and five is excellent. The PSNCQQ has
a high Cronbach's reliability estimation (0.97). Across hospital categories, reliability
estimates are comparable. The PSNCQQ consists of 19 items and three questions designed
to assess the quality of care provided throughout the hospital stay, nursing care,
and the hospital's plan to advocate for itself to others.[6 ] The researcher developed a checklist to identify the barriers to nursing care quality.
The items selected in the checklist were based on obstacles and hindrances to nursing
care quality. The options given to the patient were “yes” or “no”. Option “yes” was
coded with one mark and “no” with 0 marks. Validation of the developed tool was done
by seeking opinions from experts in the field. The reliability of the checklist to
find the nursing care quality by Cronbach alpha was 0.76. The tools were translated
into Kannada and Malayalam with the help of language experts. A pilot study was conducted
with ten subjects and the study was found to be feasible.
Using the above estimation of a single proportion formula, the investigators calculated
the sample size (α indicates the significance level, d is precision-0.1, and the anticipated
proportion is P-37). The calculated sample size was 98, which was rounded off to 100
patients.
The study included inpatients who could read and write English, Malayalam, or Kannada,
but those who had physical hardships in responding to questions were excluded. Informed
written consent was obtained from the subjects selected by convenience sampling based
on inclusion criteria, and data was collected. The study's goal and objectives were
disclosed to the participants, and confidentiality was guaranteed.
The data were analyzed using IBM Statistical Packages for Software Sciences (SPSS)
statistics version 25.
Results
The demographic characteristics revealed that 29% of patients were in the age group
of 51 to 60 years, 9% were between 20 and 30 years, slightly more than half (54%)
were males, 36% of patients were unemployed, and 12% of patients were working in government
jobs. Fifty-four percent belonged to joint families, while 6% belonged to extended
families. At least half of the subjects (41%) were undergoing chemotherapy, 45% stayed
in the hospital for one week, and only 6% stayed for more than one month. Almost half
of the participants (49%) had stage II cancer, while only 9% had stage IV cancer.
As per [Table 1 ], in this study, patients were satisfied with nurses' willingness to answer questions
(66%), communication with patients and family members (74%), involvement in care (70%),
courtesy and respect (72%), attention to patient condition (69%), recognize the opinion
(71%), adjust the schedule as needed (67%), ability to comfort patients (65%), response
to patient call (65%), skill and competence (69%), coordination of care among healthcare
providers (67%), provision of a tranquil environment (75%) and privacy (79%), discharge
instructions (75%), and post-discharge coordination of care (78%) .
Table 1
Level of patient satisfaction on the nursing care quality
(n = 100)
Sl. no.
Items
Excellent
Very good
Good
Fair
Poor
f
%
f
%
f
%
f
%
f
%
1
Information by nurses
34
34
30
30
31
31
5
5
–
–
2
Explanations about procedure
30
30.0
31
31.0
34
34.0
4
4.0
1
1.0
3
Willingness to answer
questions
37
37.0
29
29.0
30
30.0
4
4.0
0
0
4
Communication with patient and family members
34
34.0
40
40.0
26
26.0
0
0
0
0
5
Update information regularly.
29
29.0
34
34.0
31
31.0
6
6.0
0
0
6
Involvement in care
33
33.0
37
37.0
26
26.0
2
2.0
2
2.0
7
Courtesy and respect
42
42.0
30
30.0
26
26.0
2
2.0
0
0
8
Attention to patient condition
33
33.0
36
36.0
28
28.0
3
3.0
0
0
9
Recognize the opinion
37
37.0
34
34.0
25
25.0
2
2.0
2
2.0
10
Consider patients' needs
32
32.0
33
33.0
27
27.0
8
8.0
0
0
11
Adjust schedule as per
patient needs
37
37.0
30
30.0
30
30.0
2
2.0
1
1.0
12
Ability to comfort patient
37
37.0
34
34.0
24
24.0
5
5.0
0
0
13
Response to patient call
32
32.0
33
33.0
30
30.0
1
1.0
4
4.0
14
Skill and competence
33
33.0
36
36.0
28
28.0
3
3.0
0
0
15
Coordination of care between health care professionals
39
39.0
28
28.0
28
28.0
2
2.0
3
3.0
16
Provide peaceful atmosphere
35
35.0
40
40.0
21
21.0
4
4.0
0
0
17
Provision of privacy
48
48.0
31
31.0
20
20.0
1
1.0
0
0
18
Discharge instructions
45
45.0
30
30.0
17
17.0
7
7.0
1
1.0
19
Coordination of care after discharge
43
43.0
35
35.0
19
19.0
2
2.0
1
1.0
Patients in this study were dissatisfied with the information given by nurses (36%),
not receiving updated information on a regular basis (37%), not considering the patients'
needs (35%), and not receiving enough explanations about the procedure (39%).
This study also revealed that all patients who participated in this study were ready
to recommend the present hospital to others. The study findings revealed that among
highly satisfied patients, the majority were undergoing chemotherapy (92.7%), whereas
the least satisfied were undergoing radiation (68.4%).
[Table 2 ] presented the findings of overall perceptions, around 50% of patients were satisfied
with the overall quality of nursing care they received during their hospital stay,
and the overall barrier score to patient satisfaction for quality nursing care was
33.5%. Overall, 37% of patients were extremely satisfied with the quality of care
and services received during their hospital stay.
Table 2
Overall perceptions about patient care
Sl. no.
Items
Excellent
Very good
Good
Fair
Poor
f
%
f
%
f
%
f
%
f
%
1
Overall quality of care and services received during hospital stay
37
37.0
39
39.0
23
23.0
0
0
1
1.0
2
Overall quality of nursing care received during hospital stay
50
50.0
33
33.0
15
15.0
2
2.0
0
0
3
Recommend the hospital to other patients
100
100.0
0
0
0
0
0
0
0
0
[Fig. 1 ] depicts the overall barrier score to patient satisfaction related to the nursing
care quality was 33.5%. It was found that 65% of patients found the nurse's workload
as a barrier, 50% revealed time constraints, 51% felt a lack of language proficiency,
32% felt a lack of hygiene, which refers to hand hygiene practices, and 35% said that
conflicts among nurses were prevalent.
Fig. 1 Barriers to patient satisfaction on nursing care quality. HCP, healthcare professional.
In relation to the association between demographic characteristics and patient satisfaction,
it was found that occupation, type of treatment, and duration of admission had a significant
association (p < 0.05) with patient satisfaction. The calculated table value for the occupation
of the patient was 9.581 with a p -value less than 0.05 (0.048), the calculated table value for the type of treatment
was 7.521 with a p -value less than 0.05 (0.057), and the calculated table value for the type of treatment
was 12.693 with a p -value less than 0.05 (0.013). Hence, there was a significant association between
patient satisfaction and selected demographic variables.
A weak negative correlation using the Karl Pearson correlation coefficient was found
between patient satisfaction and the barriers to nursing care quality (r = − 0.12,
p > 0.05), which was not significant. As patient satisfaction increases, barriers to
nursing care quality are less perceived.
Discussion
In this study, 29% of patients were in the age group of 51 to 60 years, only 9% were
between 20 and 30 years of age, and 54% were males. Overall, 37% of patients were
satisfied with the quality of care and services received during their hospital stay,
and 50% were satisfied with the quality of nursing care.
A similar study on patient satisfaction, health condition, age, and several other
factors was used in evaluations of care done in Ostergotland, Sweden. The result indicates
that the age of the patient had the most important descriptive value for the patient
satisfaction index (PSI). Males were more satisfied than females.[7 ] According to a survey conducted in Kuwait, the overall quality is related to nursing
care quality (r = 0.36, p =0.01).[8 ] Similar results were obtained in a cross-sectional study in Turkey, with the total
data specifying a high patient satisfaction level. Nursing care satisfaction was affected
by the type of ward, gender, monthly income, and educational status. Older men with
low levels of education had higher satisfaction than the more educated.[9 ]
More than half of the patients in this study were pleased with the communication,
explanations, discharge instructions, respect for their wishes, and nurses' commitment.
In a concept analysis, the characteristics important to patient satisfaction with
nursing care were: empathetic care, health information, accurate decisions, and professional
abilities.[10 ]
According to a cross-sectional study conducted at three public hospitals, 229 (40.7%)
participants were satisfied with the care provided by nurses. Three hundred twenty-two
(57.2%) admitted patients agreed that nurses should clearly explain nursing procedures
to them before performing them.[11 ]
A patient care report about nurses' and doctors also verified missed nursing care
was treated as both an outcome measure and an explanatory factor in a cross-sectional
study. Seventy-five percent of patients had complete trust in the nurses caring for
them. Sixty-four percent of those polled said there were always or nearly always enough
nurses on duty to care for hospital patients. The most frequently missed types of
care are comforting and talking with patients, teaching patients, and family members
how to manage care after discharge.[12 ]
In this study, it was observed that 94.1% of patients who had stayed for 2 to 3 weeks
in the hospital were highly satisfied. In a cross-sectional descriptive correctional
study conducted in Saudi Arabia, among 100 patients, 86% had a high level of satisfaction
with nursing care, but disagreement rates were observed in the language (56%), discharge
information (56%), and unavailability (20%) for care.[13 ] A study in Riyadh among 424 patients exhibited a high level of patient satisfaction
in all areas. No significant satisfaction was found in male patients compared to females.[14 ] A high level of satisfaction with nursing care was also revealed in a study conducted
in China.[15 ]
In this study, the overall barrier score to patient satisfaction related to the quality
of nursing care was 33.5%. Sixty-five percent of patients found the nurse's workload
as a barrier, 50% revealed time constraints, 51% felt language proficiency, and 35%
said conflicts among nurses are prevalent.
A quantitative descriptive study conducted in the West Coast Winelands Region among
272 nurses revealed inadequacies in staffing (97%) as the main barrier. Seventy-six
percent denied receiving continuing education, and more than 80% mentioned inadequate
provision of equipment and consumables for quality patient care.[16 ] A similar study that was done in two hospitals affiliated with Alborz University
of Medical Sciences also found barriers to communication between patients and nurses.
As barriers, patients identified the nurse's gender, disinclination to respond, heavy
workload, and their own physical and psychological discomforts.[17 ] This study showed a weak negative correlation between patient satisfaction and the
barriers to nursing care quality (r = − 0.12, p > 0.05), which was not significant, whereas a study done in Kuwait showed a positive
correlation (r = 0.36, p =0.01).[8 ] A contradictory finding was also found that there was no correlation between PSI
and gender.[7 ] A study done in Saudi Arabia shows no significant correlation between patient satisfaction
and nurses' caring behaviors. Similarly, there was no significant difference between
patients' satisfaction with age, sex, previous hospitalization, and size of the ward.[18 ]
This study's limitations were that it was conducted in one hospital only and the use
of a convenience sampling technique.
Conclusion
Patients are the hospital's consumers or customers, and this study results show that
hospitals must train nurses to communicate in the local language. The quality of patient
care will be improved if there is adequate staffing and adequate training of nurses
working in oncology units. A well-planned orientation and training will enhance the
confidence of nurses. The provision of adequate essential resources will also reduce
the nurse's distress. The management needs to consider the longer working hours, which
may also reduce motivation and drain the energy of the nurses.
